Ethnic differences in respiratory disease for Native Hawaiians and Pacific Islanders: Analysis of mediation processes in two community samples

PLOS ONE RESEARCH ARTICLE Ethnic differences in respiratory disease for Native Hawaiians and Pacific Islanders: Analysis of mediation processes in two community samples Thomas A. Wills ID1*, Joseph Keawe’aimoku Kaholokula2, Pallav Pokhrel1, Ian Pagano ID1 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Cancer Prevention in the Pacific Program, University of Hawaii Cancer Center, Honolulu, Hawaii, United States of America, 2 Department of Native Hawaiian Health, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States of America * Abstract OPEN ACCESS Objective Citation: Wills TA, Kaholokula JK, Pokhrel P, Pagano I (2023) Ethnic differences in respiratory disease for Native Hawaiians and Pacific Islanders: Analysis of mediation processes in two community samples. PLoS ONE 18(8): e0290794. https://doi. org/10.1371/journal.pone.0290794 The prevalence of asthma and chronic obstructive pulmonary disorder (COPD) is elevated for Native Hawaiians but the basis for this differential is not well understood. We analyze data on asthma and COPD in two samples including Native Hawaiians Pacific Islanders, and Filipinos to determine how ethnicity is related to respiratory disease outcomes. Editor: Yasunori Sato, Keio University School of Medicine, JAPAN Methods Received: March 31, 2023 Accepted: August 15, 2023 Published: August 25, 2023 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0290794 Copyright: © 2023 Wills et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The data are available by request to the Hawaii State Department of Health, Hawaii Health Data Warehouse: https:// hhdw.org/. The data are owned by a third party, the We analyzed the 2016 and 2018 Behavioral Risk Factor Surveillance Survey (BRFSS), a telephone survey of participants ages 18 and over in the State of Hawaii. Criterion variables were a diagnosis of asthma or COPD by a health professional. Structural equation modeling tested how five hypothesized risk factors (cigarette smoking, e-cigarette use, second-hand smoke exposure, obesity, and financial stress) mediated the ethnic differential in the likelihood of disease. Age, sex, and education were included as covariates. Results Structural modeling with 2016 data showed that Native Hawaiian ethnicity was related to higher levels of the five risk factors and each risk factor was related to a higher likelihood of respiratory disease. Indirect effects were statistically significant in almost all cases, with direct effects to asthma and COPD also observed. Mediation effects through comparable pathways were also noted for Pacific Islanders and Filipinos. These findings were replicated with data from the 2018 survey. Conclusions Native Hawaiian and Pacific Islander ethnicity is associated with greater exposure to five risk factors and this accounts in part for the ethnic differential in respiratory disease PLOS ONE | https://doi.org/10.1371/journal.pone.0290794 August 25, 2023 1 / 18 PLOS ONE Hawaii State Department of Health. There are some restrictions on the data provided: HHDW will not release data on zip codes or certain other demographic information that could be used to identify an individual participant. Zip codes are restricted because Hawaii is a relatively small state with diverse ethnicity, and a person who had data on ethnicity and zip code could possibly identify a participant through deductive identification (e.g., the only female Tongan in the Kona Zip code). If there are any questions about this they can be directed to Dr Tonya Lowery St. John (). Funding: This work was supported in part by grant #P30 CA071789 from the National Cancer Institute (TAW), grant #U54 GM138062 from the National Institute of General Medical Sciences (KK), and by grants # R01 CA228905 from the National Cancer Institute and #R01 DA053766 from the National Institute on Drug Abuse (PP). The funding agencies played no role in analysis and interpretation of the data, preparation of the manuscript, and decision to submit the manuscript for publication. The content is solely the responsibility of the authors and does not necessarily reflect official policy of the U.S. Department of Health and Human Services. Competing interests: The authors declared that no competing interests exist. Mediation processes for ethnicity and respiratory disorder outcomes. The results support a social-ecological model of health disparities in this population. Implications of the findings for preventive interventions are discussed. Introduction This research examines asthma and chronic obstructive pulmonary disease (COPD) in Native Hawaiians and Pacific Islanders. Recent commentaries have observed that there is a marked underrepresentation of these populations in health research and have noted that this can undermine health equity [1,2]. Addressing this issue requires disaggregating groups that have previously been combined in prevalence research [3] and testing for differential exposures that may produce disparities in health or disease in these populations [1]. We address this by reporting disaggregated data on the prevalence of respiratory disease for Native Hawaiians and other racial/ethnic groups in the population of Hawaii, delineating ethnic differences in exposure to risk factors for these conditions, and analyzing how ethnic differences in exposure are linked to respiratory outcomes. Existing data have indicated that Native Hawaiians have the highest mortality rate for several types of cancer [4,5] and also suffer from higher rates of cardiovascular disease [6,7], which has been suggested as a factor in their lower life expectancy [8,9]. There has been less attention to respiratory conditions, such as asthma and COPD. Asthma is a common condition that affects all age groups, having an adverse impact on quality of life and health care costs [10,11]. COPD is a disease condition prevalent in adulthood and is a significant contributor to mortality both in the U.S. and worldwide [12,13]. Asthma and COPD have both been demonstrated to be risk factors for lung cancer in general populations [14,15] and among nonsmokers [16]. At present there is limited information about differences in respiratory disease for Native Hawaiians and Pacific Islanders. A 2010 telephone-based population survey indicated the prevalence of asthma among Native Hawaiian adults was 152 per 1,000 compared with 115 per 1,000 for the state as a whole [17]. Further surveys in 2 (...truncated)